Author + information
- Received July 24, 2012
- Revision received August 24, 2012
- Accepted August 31, 2012
- Published online April 1, 2013.
- Ziad Dahdouh, MD⁎ (, )
- Vincent Roule, MD,
- Thérèse Lognoné, MD,
- Rémi Sabatier, MD and
- Gilles Grollier, MD
- ↵⁎Reprint requests and correspondence
: Dr. Dahdouh Ziad, Cardiology Department, University Hospital of Caen, Avenue Cote de Nacre 14033 Caen, France
An 86-year-old woman presented with severe aortic stenosis. Left ventricular ejection fraction was 80%. Mean gradient was 55 mm Hg on transthoracic echocardiography, and the aortic valve area was 0.6 cm2/m2. Aortic valve replacement by conventional surgery was considered a high risk due to extensive ascending and cross-aortic calcification. Therefore, she was evaluated for transcatheter aortic valve implantation (TAVI). Aortic annulus sizing by transthoracic echocardiography was 19 mm. Femoral and iliac arteries evaluated by angiography (Fig. 1) and multislice computed tomography were straight with mild calcification and had adequate internal diameters. The procedure took place by right transfemoral access using a percutaneous closure device (ProStar XL Percutaneous Vascular Surgical System, Abbott Vascular, Redwood City, California). After aortic valvuloplasty with a 20-mm balloon, a 23-mm balloon-expandable Edwards-Sapien XT valve (Edwards Lifesciences LLC, Irvine, California) was successfully implanted (Fig. 2). Promptly, acute hemodynamic collapse ensued while the coronary arteries were patent and the valve was well seated with no significant intravalvular or paravalvular aortic leak (Fig. 3,Online Video 1). Transthoracic echocardiography demonstrated hemomediastinum. Aortic arch rupture was identified on angiography (Fig. 4,Online Video 2) and death occurred.
Nowadays, TAVI has become a popular technique for the management of aortic stenosis. Its indication is limited to symptomatic individuals who are at high surgical risk (1). With the expansion of TAVI worldwide, some life-threatening procedural complications have occurred (2). Severe aortic calcification, which is common in elderly patients, can increase the risk of aortic rupture during TAVI, representing mostly a fatal complication. We thought that the rupture occurred at the time of advancing the delivery system around the aortic arch, because there was some resistance at this level, with clinical manifestation appearing after the device was deployed. Therefore, careful evaluation and selection of the access site should seriously consider the benefit–risk ratio of TAVI and must be discussed on a case-by-case basis.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 24, 2012.
- Revision received August 24, 2012.
- Accepted August 31, 2012.
- American College of Cardiology Foundation